Medical aesthetic awareness among public in Malaysia and the factors that may influence it: A cross-sectional study

Abstract Introduction: Medical aesthetic practice is growing rapidly in Malaysia due to rising market demand, yet public understanding of these practices remains limited. This study evaluated the awareness and attitudes towards medical aesthetics among Malaysians. Methods: A cross-sectional survey was conducted among individuals aged > 18 years old in Malaysia from December 2021 to May 2022. The survey was distributed both online and in public settings. The survey comprised of respondents’ sociodemographic, perception of physical attractiveness, knowledge and attitude towards medical aesthetic practices. The factors influencing respondents’ attitudes towards medical aesthetic practices in the country were analysed using binary logistic regression, with the significance level set at P<0.05. Results: A total of 382 respondents participated in this study with average age of 30.81 (±9.38) years, ranging from 18 to 68 years. The majority were women (77.5%), Malay (53.7%) and Muslim (57.1%). Although most respondents had no prior experience in medical aesthetic treatment (68.1%), 76.2% respondents demonstrated good knowledge and 70.2% had positive attitude towards these services. Additionally, 53.9% of the respondents highly valued the importance of physical attractiveness. The Buddhists and Hindus exhibited more positive attitude than the Muslims. Conversely, those who placed higher importance on physical attractiveness were 0.5 times less likely to develop a positive attitude towards medical aesthetic services. Conclusion: In conclusion, despite limited experience in medical aesthetic treatments and practice, most Malaysians possess good knowledge and positive attitudes towards medical aesthetics, indicating a growing interest and potential willingness to consider these services for enhancing their appearance.


Introduction
Medical aesthetic procedures represent a relatively new eld of medical practice involving various interventions that revise or alter the appearance, colour, texture, structure or position of bodily features, which most people would otherwise consider to be within the broad range of 'normal'. 1It could include anything from minor cosmetic treatments to physical augmentation surgery as well as antiageing procedures. 2 e Malaysian Medical Council de nes medical aesthetic practice as an area of medical practice that embraces multidisciplinary modalities dedicated to creating a harmonious physical and psychological balance through evidence-based non-invasive, minimally invasive and invasive treatment modalities.
ese modalities focus on altering appearance in accordance with patients' goals and are conducted by registered medical practitioners. 3cently, there has been a notable growing demand for medical aesthetic treatments and procedures in Malaysia. 4However, recent medical aesthetic reports have highlighted concerning outcomes such as deformity and even mortality as a result of cosmetic procedures performed by unquali ed and unlicensed practitioners.For instance, a tragic case of a girl passing away following breast augmentation o ered by an unquali ed practitioner at a beauty centre has been reported, emphasising a signi cant lack of public awareness in Malaysia about the safe use of medical aesthetic treatments or procedures. 5Many consumers are likely unaware that medical aesthetic treatments or operations, as opposed to beauty salon or cosmetic medispa procedures, should be obtained only from facilities operated by a licensed medical aesthetician. 4Accordingly, the Ministry of Health (MOH) Malaysia created regulations on medical aesthetic practice to provide appropriate rules and guidelines.ese regulations require all medical professionals to demonstrate their pro ciency in the eld and undergo rigorous evaluation before being granted a Letter of Credentialing and Privileging (LCP) in medical aesthetic practice.Despite the introduction of the LCP, there remains uncertainty regarding the public's ability to di erentiate between licensed medical aesthetic clinics and beauty centres.Hence, they are encouraged to verify all necessary certi cates and credentials before undergoing any aesthetic treatment. 4 addition to raising medical aesthetic awareness, it is also critical for medical aesthetic practitioners to comprehend their customers' perception of beauty to e ectively advise and address their needs.e previous study by Redaelli et al. involving 460 respondents across Colombia, Russia, ailand, Turkey, the United Arab Emirates and Malaysia found that certain physical key features of attractiveness and a healthy lifestyle were important for graceful ageing. 6Respondents had di erent perspectives on the importance of physical attributes, emotional well-being, internal beauty and self-con dence.Further, those who had undergone medical aesthetic treatments tended to express higher levels of satisfaction than those who had not.

While Redaelli et al.'s study o ers insights into
global perspectives on beauty, attitudes and experiences, including those in Malaysia, its limited sample size prevents the generalisation of conclusions to the broader Malaysian community. 6Given the potential disparity between the perceived ideals of facial beauty among medical aesthetic practitioners and the perspectives of their patients, it becomes crucial to investigate the beauty perceptions of patients or the public. 7s, this study aimed to assess public awareness, encompassing the perceived signi cance of physical attractiveness and the knowledge and attitudes towards medical aesthetic services in Malaysia.Assessing public awareness of medical aesthetic services in Malaysia is crucial in promoting informed decision-making, enhancing healthcare planning, mitigating risks, improving provider-patient dynamics, ensuring cultural sensitivity and laying the groundwork for future developments in the eld.

Methods
is study conducted a cross-sectional survey from December 2021 to May 2022 among the general public in Malaysia.
e survey was disseminated through various online platforms including Facebook, Instagram, WhatsApp and Telegram and several public groups on Facebook such as Komuniti Selangor, Komuniti Johor Bahru and Komuniti Kedah.Respondents were further encouraged to share the survey link with their contacts, facilitating a broader reach and engagement within the target audience.Additionally, faceto-face survey distribution was conducted in public areas, including train and bus stations within Klang Valley, Selangor.Individuals who were aged ≥18 years, were Malaysian citizens and either had or had not received medical aesthetic treatment were included in the study.Conversely, individuals who had cognitive impairment, such as dementia or Alzheimer's disease; had terminally ill diseases; were unable to provide informed consent; or were unable to understand Malay or English were excluded from this study.Respondents were provided with information about the study objectives and their rights to participate in the study through a study information sheet.ey were also required to provide informed consent upon agreeing to participate in this study.For the online survey, respondents were informed that completing and submitting the questionnaire served as an indication of their consent to participate in the study.Participation in this study was voluntary, and no reimbursement was provided for respondents' involvement.][10][11] It consisted of four sections that focused on the following: A) sociodemographic and treatment characteristics, B) perceived signi cance of being physically attractive, C) knowledge of medical aesthetic services and D) attitude towards medical aesthetic services in Malaysia.Section A collected respondents' sociodemographic and treatment characteristics, such as age, sex, marital status, race, religion, residing state and location, educational level, occupation, monthly income and previous experience with medical aesthetic services.Section B consisted of nine statements that explored the perceptions of the importance of being physically attractive.Section C comprised 10 statements that assessed the knowledge of medical aesthetic practices in Malaysia and six statements that evaluated the preferred place or setting for seeking speci c medical aesthetic treatment.
e response options for Section C included 'true', 'false' and 'not sure', with a score of 1 given for 'true' and 0 for 'false' or 'not sure'.e total score for Section C was 10. rough a mean cut-o point, respondents scoring ≥6 were categorised as having good knowledge and those scoring <6 as having poor knowledge. 12Conversely, Section D utilised a 5-point Likert scale, with response options of 'strongly agree', 'agree', 'neutral', 'disagree' and 'strongly disagree'.
is section assessed the attitude towards medical aesthetic treatments in Malaysia through 10 statements related to the medical aesthetic eld.Respondents were assigned scores ranging from 1 to 5 for their responses, with negative scoring applied to questions framed negatively.rough a mean cut-o point, respondents scoring ≥27 were categorised as having positive perceptions and those scoring <27 as having negative perceptions towards medical aesthetic practices in Malaysia.
A pilot study was conducted among 30 respondents to evaluate the content validity and reliability of the survey.All questions in the survey were reviewed and assessed by an expert team comprising three academicians and two medical aesthetic practitioners.Based on the pilot study ndings, questions that were not clear were revised accordingly.e results showed Cronbach's alpha values of 0.951, 0.724 and 0.858 for Sections B, C and D, respectively.Conversely, the item-level content validity index (I-CVI) and scale-level content validity index (S-CVI) were calculated to assess the relevancy of the questions judged by the expert team.e results revealed an I-CVI of 0.75-1 for each section.Conversely, the S-CVI was 0.89, 0.84 and 0.83 for Sections B, C and D, respectively, indicating that the survey was reliable and excellent.
Data were analysed descriptively and inferentially using the Statistical Package for the Social Sciences version 23.0(IBM SPSS Statistics, New York, United states).e descriptive analysis involved the presentation of respondents' sociodemographic and treatment characteristics and scores on knowledge, perceptions and attitudes towards medical aesthetic treatments in Malaysia.Descriptive statistics such as frequencies, percentages, means, standard deviations (SDs) and medians were used where applicable.For the inferential analysis, backward binary logistic regression was utilised to assess the factors in uencing respondents' attitudes towards medical aesthetic practices in Malaysia.Prior to the analysis, a univariate test was conducted to select signi cant factors (P<0.25) for inclusion in the nal model.In the nal model analysis, factors with a P-value of <0.05 were considered statistically signi cant.

Results
A total of 382 respondents participated in this study.
e majority strongly agreed and agreed that they would become more con dent (n=97, 25.3%; n=136, 35.6%) and sociable (n=61, 16.0%; n=131, 34.3%); have better job opportunities (n=60, 15.7%; n=122, 32.0%); be more positively perceived by their colleagues (n=59, 15.4%; n=117, 30.6%); be able to nd a life partner (n=106, 27.7%; n=55, 14.4%); and be more satis ed (n=88, 23.0%; n=128, 33.5%) if they were physically attractive.Nevertheless, the respondents expressed uncertainty about the longevity of their social relationships (n=174, 45.5%), ease of establishing social relationships (n=165, 43.2%) and social acceptance (n=164, 42.9%) based on their physical attractiveness.e respondents' perceptions of the signi cance of being physically attractive are summarised in Table 2. e mean score for the knowledge of medical aesthetic services was 6.76±2.77.e majority of the respondents obtained mean scores of ≥6 (n=291, 76.2%), representing a good level of knowledge of medical aesthetic services.Most respondents were aware of the requirements to perform medical aesthetic treatments including the necessity for treatment to be administered by a certi ed aesthetic doctor with an LCP (n=270, 70.7%), the prohibition of such procedures being performed by a beautician or non-medical personnel (n=259, 67.8%) and the need for treatment to be conducted exclusively in a registered clinic or hospital (n=281, 73.6%).Additionally, the majority of the respondents agreed that all advertisements related to medical aesthetics must be approved by the MOH (n=243, 63.6%) and that patients have the right to le a complaint to regulatory bodies upon suspicion of misconduct (n=259, 67.8%).Most respondents expressed their disapproval of the safe application of speci c medical aesthetic treatment products and consumables at home such as high-acidity dark spot chemical removal products, hair removal laser devices, chemical peels and intravenous vitamin C drips.e respondents' knowledge of medical aesthetic practices is summarised in Table 3 e mean score for the attitudes towards medical aesthetic practices was 27.76±5.08.e majority of the respondents had a mean score of ≥27 (n=268, 70.2%), representing positive attitudes towards medical aesthetic practices.Most respondents strongly agreed (n=79, 20.7%) and agreed (n=148, 38.7%) that medical aesthetics contributes to enhancing physical beauty.Conversely, the majority held a neutral stance on the other statements related to aesthetic practices, including views on the potential negative impact of medical aesthetics on health and the belief that aesthetic practices in countries such as South Korea, ailand or China surpass those in Malaysia.Most respondents expressed uncertainty about whether the side e ects of aesthetic treatments are typically severe, irreversible and painful.e respondents were also unsure whether the outcomes of medical aesthetic treatments would meet their expectations or contradict their religious beliefs.e respondents' attitudes towards medical aesthetic practices are summarised in Table 4.Only religion and the perceived signi cance of being physically attractive were found to have a signi cant in uence on the respondents' attitudes towards medical aesthetic services.e Buddhists and Hindus were 3.42 and 3.44 times more likely to exhibit a positive attitude towards medical aesthetic services than the Muslims, respectively (Buddhist: odds ratio [OR]=3.415,95% con dence interval [CI]=1.111-10.497,P=0.032; Hindu: OR=3.442, 95% CI=1.763-6.718,P=0.000).e respondents with higher perception scores on the signi cance of being physically attractive were 0.5 times less likely to develop a positive attitude towards medical aesthetic services (OR=0.499,95% CI=0.292-0.850,P=0.011).ese results are summarised in Table 5.

Discussion
e current study revealed that the majority of the respondents held a positive perception regarding the importance of being physically attractive.
ey believed that possessing physical attractiveness contributes to enhanced self-con dence and self-satisfaction, consequently fostering positive interpersonal interactions.Regardless of age, physical beauty was perceived as a desirable quality and believed to yield substantial bene ts. 13 Numerous prior studies have highlighted the signi cance of physical attractiveness, linking it to various outcomes such as higher socioeconomic status, improved behavioural attitudes, enhanced social interactions,14 increased endurance 15 and heightened sexual satisfaction. 16Moreover, physical attractiveness has been associated with mating and career success, higher educational attainment and increased wages. 6,17,18Likewise, western society has also perceived physical attractiveness as an important key social factor associated with desirable traits for leading a ful lling life. 13,19Despite these positive associations, it is crucial to acknowledge that the perception of the importance of physical attractiveness may lead to potential biases, particularly in initial impressions, potentially resulting in unconscious biases. 20,21 this study, the respondents were found to have a good level of knowledge related to medical aesthetic services, particularly on legislation processes, which is in line with previous reports in Jordan and Nigeria. 12,22,23s could be attributed to the role of several platforms such as social media and internet in providing the public with exposure to relevant information.
erefore, leveraging visually engaging and interactive digital platforms such as Facebook, Instagram and YouTube becomes pivotal for practitioners in disseminating valuable information about medical aesthetics to a wide and accessible audience.Numerous studies have emphasised the value of mass media, including social media (e.g.4][25] However, while it appears that a growing number of people are becoming informed, a previous study highlighted the prevalence of misunderstandings among patients, largely stemming from false information regarding medical aesthetic procedures. 26is misinformation can lead to the development of unfavourable views and distrust towards medical aesthetic services, as individuals may become uncertain and unwilling to seek additional information on the subject. 27majority of the respondents in this study exhibited a favourable attitude towards aesthetic services, agreeing that medical aesthetics helps improve physical beauty.is nding suggests a positive connotation between medical aesthetic services and beauty.According to previous reports, the primary motivation in seeking aesthetic treatments includes increased self-esteem, beauti cation, positive ageing, transformation and correction, which depend on patients' personality and sociodemographic characteristics.20,23 However, the survey conducted by Salawu et al. among Nigerian internet users exposed negative perceptions towards aesthetic treatments, with respondents expressing hesitancy towards undergoing such procedures.12 e study suggested that age, religion, ethnic a liation and income may contribute to these negative perceptions.Understanding the speci c factors in uencing negative perceptions within a particular context requires a more in-depth analysis, potentially through qualitative research methods, to capture the nuances and intricacies of individual attitudes and beliefs.
Two factors -perceived importance of physical attractiveness and faith -had a signi cant in uence on the respondents' attitudes towards medical aesthetic services.
e respondents who had higher scores on the perceptions of the importance of being physically attractive were less likely to develop positive attitudes towards medical aesthetic treatments.One possible explanation might be that individuals who place a signi cant emphasis on the importance of physical attractiveness may have certain reservations or concerns about medical aesthetic treatments.ese concerns could include apprehensions of potential risks, fear of unnatural outcomes or cultural in uences that shape their views on cosmetic interventions.Furthermore, such individuals might be hesitant to undergo medical aesthetic treatments due to the concern that altering their appearance could result in losing their natural beauty and selfimage.Understanding these underlying factors requires further and more indepth exploration of the concerns held by individuals in the study population. 12rein, the Buddhists and Hindus were more likely to have a favourable perspective towards aesthetic services than the Muslims. is may be because some Muslims may perceive performing aesthetic treatments as a sinful act since these treatments involve altering their physical appearance deliberately.However, the stance on this issue is somewhat ambiguous in Islam. 28According to maqasid al-shari'a, which is an Islamic doctrine that promotes the well-being of all humankind while safeguarding their Islamic faith, life, mind, posterity and wealth, aesthetic treatment is permissible as long as the act does not violate general Islamic principles and is not explicitly forbidden in the Al-Quran and hadith typically subjected to Islamic scholars' fatwa in Malaysia. 29In a previous study, it was reported that individuals with a higher degree of devotion or more fervent religious beliefs exhibited a negative attitude and refused to receive medical aesthetic services. 30current study represents the rst attempt to explore public perceptions of the perceived importance of being physically attractive and knowledge and attitudes towards medical aesthetic practices in Malaysia.Its contribution to advancing understanding in this speci c context may play a role in promoting informed decision-making, enhancing healthcare planning, mitigating risks, improving provider-patient dynamics, ensuring cultural sensitivity and laying the foundation for future developments in the eld.Nevertheless, it is important to highlight a few limitations.First, the majority of the respondents were primarily residing in cities, which might have skewed the obtained responses due to di erences in the culture, tradition, knowledge and exposure compared with people living in urban areas.Second, the observed disparity in racial representation, particularly the identi cation of Indians as the second-largest population despite the Chinese being the second-largest ethnic group in Malaysia, might have been in uenced by various factors.One potential contributor is the potential variation in the response rates among di erent ethnic groups, possibly in uenced by the fact that the survey distributors were Malay and Indian.
ird, since the current study explored only a limited set of factors in uencing attitudes towards medical aesthetic services, it emphasises the necessity for a more comprehensive exploration.Acknowledging that the perception of body image is a multifaceted construct in uenced by ethical considerations related to societal norms and media in uence as well as psychological aspects such as self-perception and mental health underscores the signi cance of comprehensively understanding and addressing these facets.
is comprehensive approach is crucial for promoting a healthier and more positive body image among individuals.

Conclusion
Most people in Malaysia demonstrate good knowledge and positive attitudes towards medical aesthetic treatments despite having no prior experience.
is suggests a growing interest and potential willingness to consider medical aesthetic treatments as options for enhancing appearance.Educational campaigns and promotions should be further enhanced to disseminate reliable and trustworthy information to the public.is would help dispel any uncertainties and misconceptions related to medical aesthetic practices among the general public.Future studies should adopt a more comprehensive approach, exploring the multifaceted nature of body image perceptions by delving into the intricate interplay of ethical considerations tied to societal norms and media in uence.

Table 1 .
Summary of the respondents' sociodemographic and treatment characteristics.

Table 2 .
Summary of the respondents' perceptions of the signi cance of being physically attractive. .
As a consumer/client/patient, I can le a complaint directly to regulatory bodies such as the Malaysian Medical Council, MOH Malaysia or Aesthetic Medical Practice Division if I suspect unquali ed operators (e.g.beautician/therapist/non-LCP doctor) or unlicensed premises (e.g.beauty centre/medispa/hotel) performing medical aesthetic treatments.259 (67.8) 78 (20.4) 45 (11.8)LCP, Letter of Credentialing and Privileging; MOH, Ministry of Health

Table 4 .
Summary of the respondents' attitudes towards medical aesthetic practices.

Table 5 .
Factors in uencing the attitude towards medical aesthetic services.

Table 5 . Continued Characteristic Univariate analysis Binary logistic regression analysis
CI, con dence interval; df, degree of freedom; NS, Non-signi cance.Income and location were included in the nal model based on the signi cant level (p<0.25)from the univariate test but were found not signi cant.ey were removed from the last step in the nal model due to non-signi cance thus providing no detailed values.